Contract Pharmacy Details

MISSISSIPPI CVS PHARMACY, L.L.C.
CAH251322-00 LAIRD HOSPITAL, INC.

Covered Entity Details

Entity Name

LAIRD HOSPITAL, INC.

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH251322-00

Entity Address

25117 HWY 15 BYPASS
UNION, MS 39365

Medicare Provider Number

251322

Participating Start Date

1/1/2011

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

MISSISSIPPI CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 05835
2401 NORTH HILLS STREET
MERIDIAN, MS 39305

Pharmacy Comments

Contract Details

Approval Date

7/11/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/14/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

THOMAS BARTLETT, HOSPITAL ADMINISTRATOR
(601) 774-8214 Ext: 1500

Contract Pharmacy Representative

CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241

Signed By Date

7/11/2014

340B Drug Pricing Program Database